Medical Records Release Form Of Medical Information
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1MEDICAL RECORDS RELEASE FORM OF MEDICAL INFORMATION
PATIENT NAME______________________________________________________________________
MAIDEN NAME_____________________ ADDRESS:_______________________________________
DATE OF BIRTH____________ SOCIAL SECURITY NO____________ TELEPHONE______________
I hereby authorize and request release of
To release to Sacred Heart Health System:
records by:
______________________________________
Department of Radiation Oncology
Name
(Hospital, Clinic, Physician)
1545 Airport Blvd – Suite 1000
______________________________________
Address
Address
Pensacola
FL
32504
______________________________________
City
State
Zip
City
State
Zip
_________________
__________________
_________________
__________________
Phone#
Fax#
Phone#
Fax#
A copy of the medical records of the above-named patient pertaining to: (Check appropriate box and list
the date)
Emergency Care, Date:_______________________________________________________________
Hospitalization, Date:_________________________________________________________________
Outpatient Care, Date:________________________________________________________________
: (please check one)
CHECK APPROPRIATE BOXES
History & Physical
Discharge Summary
Immunization Records
Physical Therapy Notes
Lab
Pathology
Occupational Therapy
Pathology
X-Ray
Abstract (H&P, discharge summary, consult, OP report)
Other:_________________
REQUIRED: The purpose of the request for Medical Records is:
at the request of the patient; for diagnosis/treatment purposes; other. Explain_______________
REQUIRED: _____ I DO _____ I DO NOT authorization the release of information, including, if
applicable, specific laboratory tests of HIV Infection (Human immunodeficient Virus, the causative agent
of AIDS) or the diagnosis of Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions, all
medical records or other information regarding my treatment, hospitalization including psychological or
psychiatric impairment, drug abuse and/or alcoholism or sickle cell anemia.
Releasor, its agents and employees, are hereby authorized to obtain, inspect and reproduce such
records and/or information and are hereby relieve of any responsibility or liability that may arise from
the release or reproduction of such records and/or information in accordance with this Authorization.
This authorization will expire one (1) year from the date of my signature.
I understand that I have the right to revoke this Authorization, if the revocation is in writing except if
(i) Releasor has taken action in reliance upon this Authorization, or (ii) if this authorization was given
as a condition of obtaining insurance coverage, other law provides that the insurance company has
the right to contest a claim under the insurance policy.
I understand that I may revoke this Authorization by providing a written revocation to the provider
from which records are requested in the box above.
I understand that my Protected Health Information (PHI) that is used or disclosed under this
Authorization may be subject to redisclosure by the recipient, and the privacy of my PHI may no
longer be protected by law.
_____________________________________________
_____________________________________________
Signature of Patient
Date
_____________________________________________
_____________________________________________
Authorization Representative, If Patient unable to Sign
Description of Authorization Representative
_____________________________________________
_____________________________________________
Witness
Date
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